Book of Medical Disorders in Pregnancy - Tintash

elated to the intercellular ground
substance. It does contain some lipids
but its basic composition is entirely
different from that of the pathologic
lesions of atherosclerosis. The juvenile
diabetic (developing diabetes before age
16) frequently has significant renal
vascular disease after 10 years, and
almost definitely after 20 years.
Asymptomatic bacteriuria in diabetic
pregnancies is twice or three times as
Common as in nondiabetic and it is
likely that the incidence of
pyelonephritis, premature delivery and
renovascular complications is
proportionately increased.
Patients with renal disease secondary to
diabetes should be discouraged to get
pregnant. If they do so, and signs of
renal failure such as azotemia develop,
the pregnancy should be terminated and
tubal ligation advised.
If the OGTT is performed at or before 16
weeks gestation, a negative result does
not necessarily exclude future problems
and if the results are border line the test
should be repeated between 32 and 34
weeks. Early diagnosis of GDM is
associated with poor maternal and fetal
out come. Rather than suggesting that
management is counterproductive, this
probably means that the more severe
cases present earlier. Treatment of
gestational diabetes reduces serious
perinatal morbidity and may also
improve the woman's health related
quality of life.
Management:
If there is gross abnormality of blood
sugar this must be corrected as a matter
of urgency an ultrasound examination
should be performed to assess for
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macrosomia. This is usually taken as
dimensions above the 95 th percentile for
that period of gestation. If it is present
dietary management is required but it
may also be necessary to use insulin to
obtain suitable glucose levels. This
management causes a modest but consistent
reduction in the weight of the
baby. Measurement of abdominal circumference
of the baby can exclude
macrosomia and reduce the need for
insulin without impairing outcome. A
paper from the USA described the use of
glyburide (glibenclamide in UK) in
GDM with some benefit but possibly an
increased risk of preeclampsia. This is
unusual as Sulphonylurea are usually
used in type 2 diabetes and such drugs
are usually avoided in pregnancy. Lispro
has also been used with possible benefit.
If there is no macrosomia but glucose
levels are in the diabetic range, intensive
therapy is required as in diabetes If, after
dietary advice, fasting glucose levels
exceed 6mmol or l and 2 hours postprandial
the figure is over 7mmol or l,
then intensive therapy is required if there
is no macrosomia, and glucose levels are
not grossly abnormal, intensive therapy
should be avoided as it may be
counterproductive.
If the fetus is small for dates in women
on intensive therapy, the outcome for the
baby is poorer than if the baby is normal
or large. This is probably a reflection of
placental inadequacy if there is no
macrosomia and after dietary advice the
blood glucose levels before and after
meals are normal, treat as normal.
Prognosis: GDM is a variable disease
with different criteria for diagnosis and
different degrees of severity. Hence it is
impossible to be clear about prognosis
but some features do seem apparent.
The risk to mother and baby are similar
to those with known diabetes. This is